Choosing our narrative wisely

Family medicine recommendation 8

Do not do annual physical examinations in asymptomatic adults with no important risk factors.

Recall and describe a clinical encounter in which you were called on to choose wisely

The coronavirus disease 2019 (COVID-19) pandemic has called on me to choose wisely in my practice. It has also meant that patients are rather receptive to this approach! I noticed a difference in being able to avoid unnecessary “annual physicals.”

Given that much of my practice has shifted to telephone or virtual consultations, we are able to have conversations about whether different parts of care are necessary or unnecessary. Laboratory test use is way down. Previously, patients tended to want to do more laboratory tests, but now they are much more receptive to the approach that more is not always better. For example, a patient might say, “My hemoglobin A_1c has been pretty stable. Let’s wait to recheck things until the fall.” Patients now understand the act of going for tests presents a risk of COVID-19 contact. They are weighing the upsides and downsides of testing like never before.

Patients are not even requesting health examinations right now; they are booking for specific issues. When we discuss that issue, we do a health review. For example, while I have them on the telephone, I check functional status, screening, and immunizations to see if there are any loose ends that we will need to address after COVID-19.

In your exchange with the patient, how did you raise the need to choose wisely?

The pandemic has opened a window of opportunity to have discussions with patients about what is and what is not necessary. If they are feeling well and meeting evidence- based prevention requirements, then we are not doing a laboratory investigation unless indicated by some other risk factor. Because patients are more reluctant to go to the laboratory, we are spending time having deeper conversations and overall there are fewer investigations.

I notice that some patients have delayed or waited to seek care during the COVID-19 pandemic. They have parked their concerns and are not sure how to prioritize them. Obviously if they are now reaching out to me, the issue has not gone away and they can be fearful that they have lost time. This requires very careful listening, and can be another opportunity to discuss necessary versus unnecessary care.

What are the key elements of the communication that made it a success?

Especially now, patients are anxious. There is a need for reassurance. A key element of the communication is the plan for follow-up. I often say something along the lines of, “We’d like to reassess you in about 4 weeks. We will investigate if there is anything more progressive or concerning.” Another part of reassurance is the acknowledgment of symptoms and the explanation of why the symptoms are not concerning to me.

I communicate using plain language and I establish a time for follow-up. I might use the line, “What I am hearing from you is that you have these symptoms and they have fluctuated over time. I am not worried that there is anything sinister going on right now.” The receptionist then arranges a repeat telephone appointment within the specified period.

Patients are under increased stress because of the pandemic. For many who are older or elderly, they have not been seeing their families and are not hugging their grandchildren. Patients have time at home to think more about somatic feelings, so a mild headache becomes more worrisome. When we are busy and distracted, and out and about and socializing, we do not worry as much about these somatic symptoms.

In the end, reassurance, simple explanations about their symptoms, and a plan for follow-up can help reassure patients—without the need for unnecessary or “low-value” investigations. And the annual physical—which is really my opportunity to review their care—can be done largely by telephone.